United Healthcare

[JimG454455]

Just curious when you guys are going to address and speak to this issue. My guess is many of your members are negatively affected by Advantage plans and more specifically the ones AARP endorses - United healthcare. I am currently living the nightmare of dealing with UHC. Their denial, delay and defend strategies have all been applied to my care which has had a significant negative impact to my care and recovery.  I joined AARP because of your advocacies for seniors. What is currently in the news about the horrors of our healthcare system that are affecting seniors most needs to be talked about.

The fact that AARP has been mostly silent on these matters AND endorses the worst offender is a disservice to your members. You lend your respected name, which I know your are paid handsomely for,  at the peril of your members.

The exposure and pressure to reform their cruel practices needs more coverage, not just a silent endorsement.

Please step up and help us on this issue.

Regards

Jim Groll

[LisaS961881]

Susan,

   Thank you for your insight.  
    I wanted to reply to your question -

    I was searching the DOJ website yesterday to determine if there were any new releases on that site concerning this topic.  I found none.  However, I did discover this release. .While it does not pertain to Upcoding, and these are merely allegations at this juncture, I wanted to share this link. Please note the first and second sentences of the third paragraph:

https://www.justice.gov/opa/pr/united-states-files-false-claims-act-complaint-against-three-national... 

…..and yes, “once you scratch the surface….its complicated”.

~ Lisa

[SusanM664094]

I'm sure more information will be coming out in the days to come on both types of investigations. 

[LisaS961881]

….and while I’m on vacation, I just had to take a moment to add this update to the previous conversations!

https://thehill.com/policy/healthcare/5418393-unitedhealth-doj-investigation-medicare-billing/

….still hopeful,

     ~ Lisa. 🛶 🏊 📚🌈🙏🙋🩵

[GailL1]

Old News is New News - there is certainly a lot of talk in the Washington town about this method of upcoding beneficiaries.  Several pieces of legislation have been introduced, CMS is in talks with the various large Medicare Advantage insurers on their practices.  

Plus,Medicare needs money so it seems they are pursuing this more now than in the past when I guess things just didn’t pan out for any corrections. 

CMS.gov - News Release 05/21/2025 - CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medi... 

Then there is also these risk adjustments audits that evidently had no action.

CMS.gov - Medicare Advantage Risk Adjustment Data Validation Program(last modified 07/21/2025) 

What gets me the most is why no action in past years?  

Do you think that our government has been lax about this because they don’t want to lose MA insurers - especially of the larger variety?

[Tonster521]

 @gail1 I found an article on the internet that provides an explanation of how each part of Medicare is funded. https://www.valuepenguin.com/medicare-funding#part-b Generally, I try to obtain the authors bio to make an educated guess if the author has any background in the subject. Sometimes, all you obtain is that an author has a journalism background and no direct experience. The bio for author, Jim Arvantes, indicates 20 years in the healthcare field with 7 years as the Washington Correspondent for the American Academy of Family Physicians(AAFP). So, I would say Jim is a creditable source. 

Anyway, we know that the Feds try to split the Parts B and D costs 75% and 25% with the Feds paying for 75%. I am sure that when you inform folks of that split, many are not aware. Some even believe when they contribute the $185 for Part B and $28 (average contribution) for Part D, they are paying the full costs. Maybe, using the word, "premium", causes the confusion. Folks may relate the word, "premium", with what they pay for other types of insurance such as life, auto, homeowners, etc. In any event, many folks do not know that they are receiving Federally subsidized healthcare insurance benefits (welfare benefits) called Medicare Parts B and D. So, the issue is how do you fund Medicare Advantage Plans which were established in 2003 (previously know as Medicare Choice from 1997)? It is complicated and well beyond most folk's comprehension and experience. In the simplest explanation that I can offer, the CMS developed a bid procedure for MA which establishes a base rate that varies by County and a risk adjusted rate that varies from person to person based on a review of their health. I do not know the exact protocols for the risk adjusted health review. However, I suspect that weight, blood pressure, pulse, oxygen (via Pulse/Ox device), range of motion, some memory questions, episodes of past illnesses, etc. labs, if available, are considered Essentially, information that a nurse generally obtains when you are at the doctor's office. However, many folks do not see a doctor until there is an acute health concern. Home visits by a registered nurse (RN) or an advanced practice registered nurse (APRN) have been the solution for MA. It is rare to find a doctor that does house calls. Remember, Parts B and D essentially have unlimited access to the U.S. Treasury General Fund. MA does not. So, MA has to get the risk adjustment right to obtain the funds necessary to provide benefits. 

In many articles, the word, upcoding, is used to convey that something questionable is being utilized to increase the risk adjustment component of the funding procedure. There may be findings obtained in CMS audits where that is the case and those cases need to be addressed. However, I suspect that with a 50% MA enrollment or about 30 million folks, there are probably cases that will be questioned by CMS. Maybe medical records are not complete or missing. I do not expect that auditors are going to challenge documented medical conditions. So, no matter what approach CMS uses to allocate money to fund MA Plans, folks are going to be "floored" by the amounts of money for about 30 million folks (6o million x 50%) enrolled with MA. For example, if the Federal money was simply based on a percentage basis, the $452 Billion for Part B would amount to $7,533 per person (50% X $452 Billion divided by 30 million folks). The Part D is more complicated because not every person enrolls in Part D, monthly contributions vary (if any), and MA Plans provide RX benefits to just about all enrolled (Close to100%). Nonetheless, I developed an allocation based on 73% of $105.8 Billion or $77.234 Billion. Using 30 Million Folks, I arrived at $2,574 per person with the assumption that there is no additional monthly contribution from the MA folks. That amount can be reduced with exact numbers rather than the best estimates that I used. In other words, the remaining 23% is a combination of Part D premiums (contributions) and State payments for dual coverage Medicare/Medicaid. So, that is about $10,000 per MA enrolled based on the percentage splits that I used. It is not an exact science. The 50%/50% approach would cause a shortfall to the MA Plans inasmuch as some folks may have greater morbidity. MA Plans do not have unlimited access to the U.S. Treasury General Fund wherein Parts B and D do. So, MA Plans need to obtain an allocation of Federal money appropriate for the medical risk they are accepting. Otherwise, MA Plans will fail financially which is not what the CMS wants to happen. The CMS audits should uncover a limited amount of cases that have been "upcoded" incorrectly. Perhaps there are other readers that may review my calculations and offer other approaches.

[TRL1111]

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@Tonster521 wrote:

However, many folks do not see a doctor until there is an acute health concern. Home visits by a registered nurse (RN) or an advanced practice registered nurse (APRN) have been the solution for MA.

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Somehow I managed to find the above in your wall of text.  If folks aren't seeing a doctor for a condition, then the Advantage plan isn't paying any bills because of it.  If the Advantage plan isn't shelling out any money for it, then why should the government be giving them more money because of it?

[Tonster521]

@TRL1111, As I understand MA, you need to select a primary care physician. If you do not schedule an initial patient/doctor visit (essentially routine visit), the MA Plan will continue to contact you to do so even offering a home visit. I understand that some MA Plans will provide an incentive to schedule a home visit. So, the MA Plans pursue either "face to face" approach/visit. I believe this is how an initial health evaluation is accomplished. This is when folks are diagnosed and follow up treatment is established. I am not aware of any doctor in a fee for service plan (i.e., Medicare Part B) that does this initial health evaluation. I believe Part B provides an annual wellness exam/visit. However, the person needs to request/schedule such exam.

[TRL1111]

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@Tonster521 wrote:

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I believe this is how an initial health evaluation is accomplished. This is when folks are diagnosed and follow up treatment is established.

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If you read the WSJ investigation, you'll see that the people who were being upcoded already had doctors.  The Advantage insurance companies get their members' medical records from their doctors.  The doctors have already diagnosed people's conditions.

And you mentioned an annual wellness visit that's covered by Part B for people with traditional Medicare.  However, that's not a hands-on physical like most people are used to.  It's more of an interview and doesn't involve diagnosing conditions.  A lot of people are disappointed to find out that under traditional Medicare, if they want an annual check-up, they have to pay for it out of pocket.  Or worse, they don't find out until after their visit that when their doctor went outside the bounds of what's covered in an annual wellness visit into the realm of a physical like most people are used to getting, they're going to get a bill from the doctor because Medicare doesn't cover that.

[GailL1]

@Tonster521 There maybe some Medicare Advantage plans that do such services - perhaps those that are writing the Speical Needs MA plans.  But this is different - this is about the use of the Risk Adjustment methodology that some of the MA insurers have initiated to up their payments for those who are sicker.

CMS began implementing risk adjustment for Medicare Advantage (MA) plans in 2004. This marked a shift from a system that relied solely on demographic information to one that also considered the health status of enrollees when determining payments to MA plans. 

Here's a more detailed breakdown:

• Initial Implementation (2004):

  The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) mandated the use of a risk adjustment model, known as the CMS-HCC model, for MA plans starting in 2004. This model was designed to adjust payments based on the health status of beneficiaries, with a portion of the payment based on the new risk adjuster. 
• Phase-in Period:

  The implementation of the CMS-HCC model was phased in over several years. In 2004, 30% of a plan's payment was based on the risk adjuster, increasing to 50% in 2005, 75% in 2006, and fully implemented in 2007. 
• Evolution of Risk Adjustment:

  CMS has continued to refine and update the risk adjustment model over time, incorporating new conditions and data sources to improve accuracy and responsiveness to changes in beneficiary health status. 

  BUT THEY SEEMED TO HAVE FAILED IN THEIR OVERSIGHT.  
• Current Auditing Efforts:

  In recent years, CMS has increased its focus on Risk Adjustment Data Validation (RADV) audits to ensure the accuracy of diagnoses used for risk adjustment, with plans to extrapolate findings across entire populations. 

  The new rules now are that every diagnosis has to be validated by physicians notes in the chart.  

  Yes, the plans do need to be paid more for those that are sicker and are costing them more - it is the validation of this measure that now has to be verified with an audit not just on the hearsay of some home care visit or any other way.  

[CBtoo]

Speaking of risk adjustment, Bloomberg Prognosis published an article today (in the email I get anyway) that states that the insurers who write senior plans really messed up this year with how "priced" advantage plans and benefits in them (as in profits aren't nearly as high). 

It is titled "The Price is Wrong". 

The first two paragraphs are copy/paste below (likely I can't put it all here for copyright reasons and it is long). The are writing about medicare, medicaid and ACA plans.

"Every year, number crunchers at US health insurance companies look at their enrolled populations and calculate how many of them will break their arms, require a heart stent or be diagnosed with cancer. They use these figures to determine how much to charge in premiums to be able to cover patients' medical issues and still make a profit.

This year, the number crunchers have been spectacularly wrong — and that means prices are going up next year."

From a bit further in the article:
"On top of the policy changes, health insurance companies say medical expenses are being driven up by expensive drugs, more demand for mental health and substance abuse treatment, and aggressive billing by hospitals and other providers."

Clip again

"Medical costs in the broader commercial market are set to rise by 8.5% next year, according to a survey of actuaries by PwC. To cover costs going forward, insurers raise prices."

And another clip:
"With future insurance in doubt, patients may be seeking more medical care now while they still have coverage. That's set to boost medical spending this year, Centene said. It's another element of uncertainty in a business that hinges on making accurate predictions — and can unravel when they're wrong. — John Tozzi​"

WhIle some of the article is not about medicare, most of what they write about applies to all. PLUS with the budget deficit we will now have there will be a $500 BILLION cut to mediare over the next 10 years. A law from 2010 triggered this because of how high our deficit will be. 

In my opinion this means ALL of us will be in trouble with rates going up to cover reduced funding coupled with social security cuts by 26% in 2033 if we don't act to solve that one. Too bad I am young enough not to be dead then so as not to have to worry about it  LOL (that's a joke folks, a dark joke).

[GailL1]

@CBtoo 

Yep - get ready.

Medicare Part B premiums 

Medigap Premiums 

Medicare Part D cost

Medicare Advantage plans cost

There are almost 70 million of us on Medicare and more everyday and there is one thing that we all seem to do quite well - use our healthcare.  From preventive services to the new mental health coverage to the expensive weight loss drugs - although they are supposed to be for other DX than just straight weight loss.  

[Tonster521]

@gail1, Thanks for the info. It would be interesting to know the methodology that MA Plans use for affecting risk adjustments evaluations (RAE). Do they use medical info obtained from Physician visits (outpatient/inpatient), RNs, APRNs, Physician Assistants, or a combination of all? Or does a person with a past medical background or even a non-medical background (insurance company employees) make the RAE? Or is the RAE the result of computer program that utilizes ICD codes? I have not been in the healthcare funding business for about 20 years (2005). Back then, there were tens of thousand of ICD codes, maybe 50,000, is my guess. As I remember, the diagnoses with the greatest amount of codes were Cardio Vascular and Diabetes. The morbidity varied from person to person. I do not know nor could I find on the internet the formula that the CMS established for RAE payments. Moreover, if such formulas exist, they may change from year to year due to changes in medical procedures, new drugs, etc. In other words, some are dynamic or changing. 

From an auditing perspective, it looks like they CMS was initially overwhelmed by the amount of folks that elected MA over Traditional Medicare. I do not think that anyone expected more than 50% enrollment in MA. The forecast is even for greater percentages in the future, maybe as much as 65%. So, how could CMS address such exponential growth in MA and their audit requirements? They would have needed an army of auditors which they still need today in order to audit 20 to 30 million RAEs. I suspect CMS will outsource the "hands on" RAEs to a third party. That will provide at least some "arms length" protection against any litigation that may arise. As you know, CMS enters into contracts with MA insurers who have been in the healthcare risk business for years; and ,have not only empirical data, but also actuarial data regarding morbidity. As you know, we do not get healthier as we age. Statistics inform us that the chances (probability) of illness/disability is greater than death. The CMS knows this as well. 

As I mentioned in my reply, the audit will focus on medical records that are incomplete or missing information/pertinent data. In many cases, physicians are not sitting at keyboards entering data obtained from visits, laboratory, xrays, hospital confinements, etc. into medical records. For example, I live in an urban area with hundreds if not thousands of physicians within a half hour drive. Most, if not all, are connected to large physician groups that have administrative folks that type (enter data) via keyboards into computer databases/records at lightning speed. I am sure that there are still some physicians who are not part of large physician groups or are in rural areas that cannot cover the costs of extra administrative folks. So, any increased CMS audits will focus on record keeping. It is a start to determine if there was any skullduggery. If not, but medical records are incomplete and/or missing data, it will require MA insurers to increase their administrative staff and that will increase the cost of MA Plans. I do not believe the CMS wants to drive the MA insurers out of offering MA Plans and accepting healthcare risk.  

[CBtoo]

I think the exponential growth in Medicare Advantage plans is because agents write, something like, 65% of them and they get paid more than twice as much to write them vs a supplement and D. So duh if all of their income comes from commissions what are many of them going to do? Write Advantage plans as they will make more. They could solve that by making the commission the same across all plans advantage or supplements (plus D together) just for starters.

Sure some would still choose an advantage plan due to some of the other "freebies" however not all people who choose them qualify for food cards, etc. If one compares the max out of pocket of an advantage plan vs any supplement, supplement's win if you are going to hit the max. Further, since you have to pass medical underwriting to get into a supplement when your health declines and you now find them "cheaper" than an advantage plan, many won't, Of course preventing people from switching keeps the supplements full of healthy people too, not just the sickest of the sick...

There are no easy answers but when they are rewarding agents more for writing advantage plans than supplements and D, it is no surprise that the growth of them is huge, 

[GailL1]

@CBtoo 

Maybe a good idea to review who they are and what they do and how

MEDPAC.gov - 03/06/2025- Medicare Insurance Agents 

MedPac.gov advises Congress on Medicare matters. 

It isn’t as “free market” as you think.  Medicare Part C (and Part D) are part of Medicare and thus CMS has a lot of influence on the plans, the marketing and the agents education and compensation. It is all covered by law - Title 42 -The Public Health and Welfare - The Code of Federal Regulations Title 42 contains the codified U.S. Federal laws and regulations that are in effect as of the date of the publication pertaining to public health in the United States and its territories, including Medicare and Medicaid.

CMS sets the rates - increases or lowers them for MAPD plans and Part D plans.  

CMS issues the rules on all MA plans - all different types.  If a new concept is offered - like the “give back” MA plans, CMS writes the parameters of these plans.

CMS writes the rules on how MA plans (and Part D plans) can be marketed, how agent brokers are compensated depending on whether they are capitive agents  or employees of just one company or whether they are independent and write for many plans that are offered in the areas where they work.

CMS.gov- 2025 Agent and Broker Training & Testing Guidelines 

CMS.gov - Medicare Marketing Guidelines

CMS.gov - Agent Broker Compensation  

CMS.gov- Marketing Models, Standard Documents, and Educational Material 

These independent agent, can’t speak to the capitive agents, have to pass state license requirements and know their products as well as Medicare as a whole program.  They also are in the business of helping beneficiaries find the right plan for their needs. That could be a Part D plan or a Medicare Advantage plan with an included Part D which most are nowadays.  

If somebody is prescribed a med that is not on their current formulary, they can work with the beneficiary to get and exception and some pricing help.  They help beneficiaries learn how to use their “extra benefits cards”, to get food, pay their utilities or buy OTC health needs.  

They help the beneficiary find the right MAPD plan that meets their needs, the type of plan and their pocketbook - a provider that they particularly want in-network or how a PPO out of network would work for them.  Their specific medications and now this year, how the maximum out of pocket works.  

Now remember that these agents/brokers want the beneficiary to be pleased with their choice of MA plans since any subsequent compensation would come from reupping their plan every year with the same plan or another from their efforts. 

[CBtoo]

I only saw this. A lot of what you are criticizing me for has nothing to do with my post.

I am on a medicare agent forum (I am not an agent but it certainly is enlightening to be on there) and what many of them, but certainly not all of them, are say is appalling.

Regardless of what the rules are some agents will NOT tell people about plans they don't get commissions for or companies they are not able to write for. Others will tell and direct them elsewhere if they don't want to write a no commission advantage or D plan or aren't signed up with that insurance company to write for them.

When agents get 100% of their money from commissions and the commissions for writing an advantage plan are twice as much or more than writing a supplement and D, many steer people into advantage plans as they make more money.

Research documents that people tend to be loyal to agents they like who help them EVEN if they end up paying more or are unhappy with some of what they signed up for. 

As long as the client is reasonably healthy and the doctors they see are in network most are reasonably happy with their advantage plan. More of the problems start when they start to have expensive health issues, so their costs rise since the max out of pocket is higher in advantage plans (than in premiums plus out of pocket with supplements) and then some discover they can't switch to a supplement because they fail medical underwriting. Or they end up wanting care with someone out of network and switching their advantage plan means they lose other doctors they want to keep. But then their choices are often limited and they stick with their agent because they like their agent. 

BUT that is different from what I was answering. Agents make their most money when they sign someone up, not when they renew (this is both for advantage plans and supplements/D's). Losing a client later in the game "costs" them less financially. When you look at those just turning 65 more of them sign up for an advantage plan and something like 70% use agents. Many agents steer clients to what pays them more, regardless of the rules. This is the classic, "Folly of rewarding for A while expecting B". 

[GailL1]

@CBtoo   I suggest that you go directly to Reddit Medicare and speak with some agents there - these agents spend their time answering questions and giving directions to Medicare beneficiaries - some with very unique problems.  

All insurance agents make their income from commissions from policies - all types of insurance - to hopefully develop an ongoing income stream, many of them work very hard to keep their clients happy and yes, help them.  

Many of them sell all types of Medicare coverage - MAPD, MA, Medigap, Part D free standing plans - They don’t just sell, they help their clients with their plans and any problem that might crop up.  

Just like my independent insurance agent, he sells for several different companies but not all and will present to me the coverage and the insurer that best fits my needs - auto, home, liability, life - then I can take it or leave it and search elsewhere.  

We have Medicare insurance agents who are independent that write for several different companies and plans available in their state - but not all of them.  In fact, many Medicare plans - Part D, MAPD, Medigap - have never had actual community located agents rather they are captive agents and sell only thru the [insurance] companies website.  (like UHC}. 

[CBtoo]

I have no need for an agent. Not sure why you think I do and suggested to go to reddit.

I also stated, as you did, agents make their money from commissions. That creates an automatic conflict of interest when some plans don't pay a commission. Some agents are more ethical than others. Some will not sell something without a commission nor tell potential clients about them. This move to no commission puts agents between a rock and a hard place. BUT those who do that may not match the clients with the plan that best suits their needs. Advantage plans pay a much higher commission than supps + D. That does, based on what is being posted on the forum I am on, influence what some agents will even tell clients about. Sure there are agents who will answer questions and help people (and some likely are hoping they will then have others see they are helpful and want them as their agent - I posted about something on reddit and my private messages blew up with agents for that offering their services).

I knew I wanted a community rated supplement due to how the risk pool is structured and how that affects premium prices when one is much older (and people live a long time in my family - 90's and 100's), there was only one choice (UHC) and so that was that, Bought it directly. I put my meds in D each year on medicare.gov and choose the cheapest of the 3 star and above. Switched my D 4 times in 6 years so far. Saved a lot of money doing that.

[TRL1111]

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@Tonster521 wrote:

It is a start to determine if there was any skullduggery. 

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IF you're talking about Advantage insurance companies using home visits to upcode their members and add diagnoses that their doctors haven't made, then it's not "if" there was any skullduggery. 

From the Wall Street Journal article about its investigation:

----------------------------------

"Some diagnoses claimed by insurers were demonstrably false, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert.

'It’s anatomically impossible,' said Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham. 'Once a lens is removed, the cataract never comes back.'

Another 36,000 diabetic cataract patients didn’t receive any medical services or prescription drugs related to diabetes."

---------------------------------------

And yet the insurance company was paid extra by the government because of the diagnosis the insurance company made.

The first part of the article is about a woman who got a $50 gift card in exchange for agreeing to a home visit.  "A nurse showed up, checked her over, asked her questions, then diagnosed her with diabetic cataracts...But [she] doesn’t have diabetes, her own doctor later said, let alone the cloudy vision sometimes caused by the disease."

It looks like the article might not be behind a paywall right now:

wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d?st=6pcf66tdkujtg9f&r... 

[Tonster521]

@TRL1111, I am sure you know that by the time one attains age 65, the vast majority of folks have health issues. Some issues are more serious than others. Some folks acknowledge the issues by obtaining a medical opinion and treatment. Some do not. The CMS has the job of distributing tax dollars via protocols to the various approaches for medical care: Traditional medicare and MA (i.e., HMO, PPO,POS, etc.) so that it is as equitable as it can be. There are various numbers that appear from article to article that indicate the costs for the various approaches. You can pick any cost from the articles and work back to arrive at a cost per person. However, you will find that the amounts vary from author to author. So, I suggest to use amounts that SS Actuary uses currently for Part B which is approximately $740/month or $8,880/year. Most of us pay $185 or 25% of that cost and the Government pays the other $555 of that cost. Is it an exact science? No, in any given year actual costs may be lower, the same, or greater based on morbidity that varies. More important, how many folks who were once average are now above average health risk or even catastrophic? The article that you linked from the WSJ indicates that MA Plans receive a base of $3,735 per person which is less than 50% of the Part B average of $8,880. So, the CMS created an approach using Risk Assessment Evaluations (RAE) to be equitable. Otherwise, CMS would not have any bidders to accept such health care risk wherein you are guaranteed to fail. So, is the CMS approach the correct methodology? 

I thought it may be a good idea to provide statistics for a medical issue such as hypertension so the readers have a better understanding of medical issues in the over age 65 population.  https://www.cdc.gov/high-blood-pressure/data-research/facts-stats/index.html#:~:text=In%202023%2C%20... The statistics indicate indicate almost 50% of folks over age 65 have hypertension. You can drill further and find other articles that indicate the percentage that are not treated or do not follow treatment protocols. The article that you linked discusses cataracts including diabetic cataracts. So, here are more statistics on diabetes including the over age 65 population. https://www.cdc.gov/diabetes/php/data-research/index.html#:~:text=Prevalence%20of%20both%20diagnosed...). As you may not know, diabetes is a terrible diagnosis and a continuing day to day challenge for the folks with diabetes. I am adding another link that provides pertinent information about diabetes and cataracts. https://pmc.ncbi.nlm.nih.gov/articles/PMC6422859/  The questions are: should MA Plans receive more than the $3,735 base; and, if so, how much more? 

The WSJ article that you linked has an agenda. I did not read about any solutions to the RAE approach. I did not read if the WSJ determined the protocol that MA Plans use and CMS accepts is an issue or is it incorrect/inaccurate RAE by the RN, APRN, or Physician or is it a computer program created to increase morbidity or something else such as a third party vendor simply making inept decisions. As you may not know, medicine/healthcare is not an exact science. Medical practitioners provide opinions. Sometimes they are right and sometimes they are not right. If you have ever witnessed medical litigation, you will find physicians testify a person has a severe loss or totally disabled and another physician testify that same person has minimal issues and can return to work. The SSA deals with thousands of cases like the above. 

As I mentioned in a previous reply, the CMS should review the cases that the WSJ identified. CMS should determine if the appropriate protocols were used. If not, were there mistakes, incorrect assessments, or outright fraud. Depending on the results, appropriate action should be taken by the CMS.

[TRL1111]

I've never said I have a problem with Advantage plans being paid more for members who have health conditions that result in Advantage plans having to pay more money on their behalf.

What I do have a problem with, and have said so over and over, is insurance companies being allowed to decide what conditions their members have, regardless of what the member's own doctor says, especially when the insurance company will make more money for each condition they diagnose.  Sure, it's possible someone could have a condition they haven't sought medical treatment for, and therefore have no doctor diagnosis, but realistically, how many of these would be revealed in a home health visit?  And even if they are revealed in a home health visit, if the person goes to a doctor about it, the doctor will enter the diagnosis, which will trigger the extra money for the Advantage plan.  Sure seems like a route that's less open to fraud than someone who's not a member's doctor just entering a few keystrokes on a computer and...viola!  Extra money for the insurance company!

And not discussed so far is that it's not just the insurance companies making extra money that's problematic.  The member may not even know the insurance company has given them a particular diagnosis, and might find out only when they decide to switch to traditional Medicare and buy a supplement, and they fail underwriting because of the insurance company's diagnosis.  

[Tonster521]

@TRL1111, I forgot to add the 2024 NAIC Report https://content.naic.org/sites/default/files/2024-annual-health-industry-commentary.pdf I got timed out and forgot to add the Report after the reload. The data on the healthcare industry should be helpful. The industry is not a big money maker like I-Phones. What is amazing to me is that folks continue to pay about 5 times the cost of production of an I-Phone. Yet, for Medicare Part B, we pay 1/4 times or 25% of the cost. The Federal Government picks up the other 75%.

[Tonster521]

@TRL1111, Once again, it appears to me that you are suggesting that the RAE procedure established by the CMS is subject to fraud. And, it can be, but it is due to people such as Physicians, RNs, APRNs, maybe Physician Assistants, others in the Medical field with titles I am not aware of. A human has to make a diagnosis/analysis based on an examination regardless if in an office in a Medical Building or clinic, rented office in a Hospital campus, an inpatient room during a Hospital confinement, a Community Health Center, or a person's home. The point is that the physical location is not critical. Although I will say that today it is easier to obtain labs, X Rays, EKGs, etc. if your Physician is located in a Medical Building that has such services available. Back in the day, you had to drive to another location and wait for results which sometimes never made it to your Physician, Physician Assistant, APRN, etc. So, record keeping has improved with one stop medical care. However, when folks have had multiple treatments from different medical practitioners, you hope that the different medical record systems are compatible, data is entered accurately, the ICD codes are correct, and the staff is conscientious identifying folks with common last names such as Smith, Johnson, Jones,etc. Many readers may not understand the additional detail that is needed just to ensure you have the correct person. When I was in the pension business (both monthly pension and retiree health insurance (self funded)), of approx.114,000 pensioners and approx. 90,000 with health benefits there were over 400 folks with both the same first and last names. We issued additional ID numbers. Because of being self funded (that means we paid health care benefits from profits, if any), each year we audited select hospital claims that exceeded dollar amounts, frequency, and every catastrophic (duration) episodes. We challenged charges that did not have written orders or were extremely high cost (the proverbial $10.00 aspirin, the $1,000 Xray, etc.. Back then, there were many hospitals using the "cook book" approach to billing and did not place much emphasis on details. The audits did not challenge medical needs or necessity, but focused on the inefficient billing activities. The results were that organizations auditing hospitals saved money. And now, each item that you receive at a hospital is scanned by the nurses unless they forget to do so. Negotiated payments including discounts, DRGs, etc. have somewhat reduced the need for detailed coordination between Medical (all departments) and Billing. The point that I am providing is that the WSJ took a shot at the details of the RAE process (which I continue to repeat) was established by the CMS. So, more audits by CMS are good and will "weed out" questionable cases not by challenging medical conditions which would need an independent medical exam, but by medical record review. In other words, reviewing the details in the medical records. I am sure that CMS auditors will find cases that will result in some savings, but I cannot imagine several millions cases out of 30 million folks enrolled in MA. It would be interesting to find out the amounts paid to HMOs which may or may not use the RAE process. 

Anyway, if folks in the medical field are "cooking the books/records" in order to convey a person with greater medical needs, I would think CMS would have grounds to challenge such person's medical license/registration. If the MA insurers are using some type of computer program that is designed to increase morbidity based on just data from medical records, that program should have surfaced by now inasmuch as MA has been around for 20 years. If there were concerns about using such programs for a greater allocation, there may be fraudulent activities cases that the CMS may pursue. 

I thought it would be helpful if I added the NAIC 2024 Annual Health Industry Report which will inform readers of the ever increasing cost of Health Care. You can scroll through the Report which gets sorted by Medicare and even MediGap. The Medical Loss Ratios are in the high 80 percent category. This means almost 90% of the premiums are paid in health care benefits. You do not want to be in the health care business. 

I have some experience with folks with diabetes mostly from an employer/employee/retiree perspective; and, I mentioned in a previous reply, it is a challenging illness. I found a link to statistics that put a light on the magnitude of diabetes and prediabetes.  https://www.cdc.gov/diabetes/php/data-research/index.html#:~:text=Prevalence%20of%20both%20diagnosed...). I am surprised that the good doctor from Arizona that the WSJ used did not know that almost 50% of folks over age 65 are prediabetic and may become diabetic over time. Moreover, that average may be applicable to his patients as well. Maybe he was only addressing the complications for diabetics after cataract surgery which may take years to occur. This is why we always should obtain a second opinion if time permits. Enough said. With regard to the folks with no knowledge of their health issues (diagnosis), how many actually review their medical records/files especially if they have seen multiple medical practitioners over the years? Or, do they discuss there health with their Physicians? Do they ask questions?

[TRL1111]

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@Tonster521 wrote:

 I am surprised that the good doctor from Arizona that the WSJ used did not know that almost 50% of folks over age 65 are prediabetic and may become diabetic over time. 

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Who cares?  In fact, who cares about any of this? 

The issue is insurance companies diagnosing members with conditions for which the insurance company gets paid more money, without any involvement from any of the members' actual doctors.  The insurance companies themselves are even offering to stop it as long they all have to stop it.  

[Tonster521]

@TRL1111, I believe the patient is the most important person that should care. As you know, there are folks that do not accept medical advice (i.e., stop smoking, eat healthy, reduce weight, more exercise, drink in moderation, etc.). So, those folks don't care. Then there are folks that do not see a physician unless there is an acute episode. So, they do not care until learning of a medical problem or experiencing a physical limitation. I believe the majority of folks care about their health and will seek a new physician especially, if a physician fails to diagnose a medical/health concern or misdiagnoses a medical/health concern. This happens every day. With regard to the diabetic diagnosis, some physicians use an A1C of 7 or more to indicate diabetes. Others use 6.5 and may consider results just below 6.5 as a warning to start changing what you eat, drink, reduce or eliminate sugar, loose weight, exercise, etc. Folks receiving an early warning may be able to avoid the various medications, daily glucose monitoring, insulin, as well as possible vision and kidney complications. I am sure the good doctor from Arizona received the patient's medical records as well as the primary physician's examination results regarding the patient health status for cataract surgery. Additionally, follow up is generally done by an optometrist if the practice is large. Problems are referred back to the ophthalmologist who performed the surgery. If there are no problems, there is no need to see the such surgeon. Maybe this is the reason why the surgeon in the the WSJ article only sees a few cases.   

It is clear that you keep alleging that the insurance company is diagnosing MA members without physician involvement. It appears to me that you are basing your allegations on the WSJ article which, in my opinion, does not describe the CMS procedures at all. Unless you worked with Traditional Medicare and Medicare Advantage, you will not be aware of the details required by the CMS including entering data into the CMS system to affect MA payments. I suggest you reread GaiL1's posts/replies on July 27th and 28th and research the concepts you do not understand. If you take the time to study the issues, it should be abundantly clear that the funding MA is a CMS program/procedure and not the  insurance companies program/procedure. To help you study, I am providing a link to Medicare Managed care manual. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r118mcm.pdf The beginning informs the reader that in 2014, the Manual was revised to include ICD-10 (10th Edition with approx. 70,000 codes) which replaced ICD-9 (9th Edition with approx. 50,000 codes). When I left health care funding, ICD-9 was the governing coding program. The point is that the CMS quantifies an enormous amount of diagnoses with codes. It should be abundantly clear that people get sick when they age. It gets more complicated with various CMS Models as GaiL1 has indicated. The first and probably the most used is the CMS-HCC which uses Hierarchical Condition Categories. Once again, I suggest you scroll through the link I provided and carefully read Chapter 7 - Risk Adjustment and Chapter 8 Payments to Medicare Advantage Organizations. It should be noted that the CMS does require a "face to face" approach with a physician or a physician extended (i.e., Physician Assistant, APRN, RN, and many others noted in the Table of Physician Extended) and supporting medical records. My post/reply on July 26th informed the readers of the "face to face"requirement which was common knowledge from about 20 years ago. The MMA of 2003 provided a three year transition so 100% of the procedures were in place by 2007 including Risk Adjustment Evaluations (RAE). By providing a procedure for prospective risk adjusted payments, the CMS developed stronger incentives for MA Plans to participate in the Medicare program. Since 2007, MA has grown from about 8 million to 33 million (2024 enrollment) which is about 54% of all eligible for Medicare. It is projected to continue to grow to about 65%. Based on the current CMS procedures, MA Plans will continue to receive greater Medicare payments by design inasmuch as MA Plans have an incentive to identify as many health conditions as possible. Is that a bad design? From a health perspective, this may be a better approach since addressing health issues before they become chronic or even catastrophic has value. There is an implied assumption that folks with Traditional Medicare (TM) and MA have similar healthcare spending. We now know that is not the case since MA members have, generally, been healthier. This is referred to as Favorable Selection in funding healthcare risk Moreover, as we read in the Forum, some MA members transfer back to TM once they begin a chronic and/or catastrophic episode of illness/morbidity. Many States have passed legislation that encourages such transfers (adverse risk) by allowing folks to buy Medigap policies upon certain events such as birthdays, etc. even though the previous MA Plan has been, in effect, paid in advance for covering that risk. TM pays providers based on the number of services they provide (fee for service approach), not the number of diagnoses which is how MA is, in effect, paid.

The suggestion from Humana that prospective risk adjusted payments should be revised or eliminated does not solve the MA funding issue. The WSJ article did not indicate what might be a replacement for RAE; namely, retrospective reinsurance. In other words, CMS provides reinsurance for such chronic and catastrophic cases whether by self funding or transferring such risk to an insurance company for a premium. I have not seen any numbers on this approach and it may be a greater cost than the RAE approach. 

Lastly, you continue to state that the diagnoses are not in the MA member's medical records. If this is the case, there is a bigger problem which borders on fraud. It can affect Physicians and Physicians Extended who actually do the required face to face visit with the MA member. The WSJ article indicates that MA members do not know the medical info in their medical record. What else is new? How many folks review their medical records which are available to everyone via electronic review. Of course, you need a computer, smartphone, etc. to access your medical record along with a user name and password. Additionally, you need a printer if you want a hard copy. Otherwise, some medical offices will charge a fee for not only the time to obtain a medical record but also a copying fee. CMS audits should uncover whether the MA Plans keep two separate medical records with separate medical info. From an operational perspective, that would be a great cost to maintain and what value would that have not informing a patient/member of a health issue?

[TRL1111]

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@Tonster521 wrote:

Lastly, you continue to state that the diagnoses are not in the MA member's medical records. If this is the case, there is a bigger problem which borders on fraud.

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Yeah, fraud by the insurance companies when they diagnose conditions that are anatomically impossible.  The reason it's not in the member's medical record is that it doesn't exist.

[LisaS961881]

   TRL,

      I appreciate what you wrote in this post.  Full Disclosure - I diligently read everything that you, Gail and Tonster write on this subject - thanks!

If I just might add, there are public feedback/reviews of these  “home health visits” on the BBB website, as well as sites such as TrustPilot - you just have to search for them using the name of the subcontractor that employs the individuals who perform these visits.  As they were eleven months ago when I first searched for them, they are shocking descriptions of unprofessionalism.  Despite the recent news that the veil has been lifted and this issue is now being examined, as of this past week’s reviews, these companies have neither altered their aggressive “boiler room” tactics, nor, by and large, informed patients of the results of these visits.  (My interpretation, and I might be wrong, is that these subcontractors don’t seem to “running scared” or modifying their tactics/actions in any manner.  This concerns me.)

Again, thanks for the info.  Now that I’m 65, I need to keep myself informed about all of this.

~Lisa 🙋

[TRL1111]

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@LisaS961881 wrote:

(My interpretation, and I might be wrong, is that these subcontractors don’t seem to “running scared” or modifying their tactics/actions in any manner.  This concerns me.)

And don't forget that even Humana has said it's willing to back eliminating payments based on insurer-driven diagnoses based on home visits and medical chart reviews, unless the diagnosis is confirmed.  Of course they're not willing to stop the practice on their own, and instead want them and their competitors to be forced to do it by law, but that's to be expected of a publicly traded company because their first duty is to the shareholders.  

msn.com/en-us/money/companies/humana-to-back-curbs-to-medicare-advantage-billing-practices/ar-AA1G8n... 

If an insurance company is queasy enough about one of its income streams to be discussing it in public, that should tell you something.

[SusanM664094]

Humana is right there with UHC. This happened last year in my area, leaving many of us to scramble to switch docs mid year. We've been sandwiched in the battle of carrier vs provider. And not just my region. So far this year, my coverage is stable with a local managed care provider. Fingers crossed. 

[LisaS961881]

  TRL,

Thank you for sharing this.  

A little over a month ago, I do remember thinking, “OK, NOW we are getting somewhere” when I read that the DOJ had begun conducting targeted interviews.

 When I read “nurses told the Journal they were trained to record sometimes obscure or questionable diagnoses” in the link that you provided, I actually muttered, “Gotcha!” 😊

I realize that I need to be more patient, and that this reform is going to be a slow, grinding process.  I do find some comfort in knowing that we’ve finally left  Oz in that we are no longer being exhorted to “Pay no attention to that man behind the curtain!”.

Thanks,

     ~Lisa 🙋🌈

[CBtoo]

The trouble is "fake" diagnoses is also the problem of the electronic medical records systems. It takes nearly an act of god to get wrong stuff out of there and have it stay out of there. With EPIC (mychart) the person who put it in there has to take it out, or at least someone in that practice and not another practice using EPIC. I have been beating my head against the wall trying to get wrong diagnoses out of there, let alone get some listed as resolved. I get it fixed in one system and it doesn't usually cross over unless the person who put it in there takes it out. Um and just how can that happen when people retire, move...?

So since this happens (using the cataract example) with advantage plans, original medicare, employer insurance, ACA insurance, medicaid, etc, I'd suspect a good chunk of this is laziness on the part of someone to fix the mess in someone's medical records rather than deliberately leaving it in there. I feel like I am playing wack a mole trying to get my records fixed in "care everywhere" (a section patients can't see but various physicians have allowed me to photograph) along with with individual doctors (who often just copy/paste what they have written before without updating it)